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Weekend Digest

Name the Pathogen

Five Clues
1. Tumbling #GPB
2. #Pregnancy
3. #Delicatessen
4. #Meningoencephalitis
5. #Ampicillin + #gentamicin Image
#Listeria monocytogenes

High-risk foods: unpasteurized cheeses, hot dogs and deli/lunchmeats.

High-risk groups:
- pregnant women
- newborns
- older adults
- people with weakened immune systems
#Listeriosis in pregnancy
1. Febrile gastroenteritis
2. Bacteremia
3. CNS infection uncommon

Most common in 3rd trimester

Listeria can cross placental barrier —> fetal death, premature birth, infected newborn

Granulomatosis infantiseptica…
Read 4 tweets
Weekend Digest

Name the Pathogen

Five Clues
1. Gram-positive bacillus with tumbling motility
2. Food safety
3. Age, pregnancy and steroids
4. Rhombencephalitis
5. Ampicillin+Gentamicin Image
#Listeria monocytogenes

Decaying plant matter

Processed/unprocessed food (deli meats, hotdog, soft cheese, pate, fruits, greens/salads)

Oral route —> intestinal mucosa penetration —> systemic infection
#Listeria monocytogenes and food safety!

Listeria survives in refrigeration temperature

Sporadic isolated cases
Occasional outbreaks due to food contamination (see link for recent outbreak)…
Read 8 tweets
#Cefalea Puntos claves: anamnesis y examen clínico inicial.
∙ Evaluar gravedad: puede ir desde leve a alta intensidad (“la más grave de la vida del paciente”). Este último grado de intensidad puede apreciarse en cefalea tipo “trueno” u otros tipos de cefalea de altísima intensidad y brusca aparición y necesita atención prioritaria.
∙ Antecedentes: hay que hacer énfasis en el estado de inmunosupresión del paciente, especialmente en presencia de cáncer o infección por virus de inmunodeficiencia humana (VIH).
Read 11 tweets
#SíndromePulmónRiñón: Ayudas diagnósticas
Radiología: infiltrados con patrón alveolar de distribución simétrica, predominio central y en bases pulmonares; sin embargo, hay casos en los que los hallazgos pueden ser focales – unilaterales y discernir con otras entidades puede ser difícil.
Gasimetría arterial: hipoxemia (PaO2 menor de 60mmHg); el mecanismo de esta condición es secundaria a “shunt” y alteración de la difusión, lo que explica la pobre respuesta al oxígeno a alto flujo en la mayoría de los casos.
Read 10 tweets
Time for some #SpacedRepetition from @CPSolvers @DxRxEdu @rabihmgeha

Some chat recap #ClinicalPearls and bonus pearls from #VirtualMorningReport on Friday Sept 25th…

Case by the brilliant @Rafameed Image
A 31-year-old M born and raised in Brazil w/ no PMH presented with a 3 mon history of worsening DOE, orthopnea, 7kg weight loss, abdominal distention, dry cough, and syncope

Base rate of disease for an ID case with @k_vaishnani and @Rafameed is very high
An interesting fact from @3owllearning : Depending on the clinical problems, the studies of disease probability for differential diagnosis often show 10 - 25% of cases are unexplained, even after careful examination and testing.
Read 17 tweets
Time for some #SpacedRepetition: @CPSolvers @DxRxEdu @rabihmgeha @dminter89
Chat recap of the #ClinicalPearls #VirtualMorningReport

Episode 140 - Virtual Morning Report - September 11, 2020… Image
Let's start with an initial PR:

A 27 y/o male with no PMH from Mexico presents with 10 days of generalized abd pain, vomiting, diarrhea, fever, & yellowing of his eyes

Deploy our Jaundice Schema;…
Other causes of yellow skin, e.g. excess beta carotene, usually do not cause deposition in conjunctiva or sclera, so eyes aren’t yellow

sounds biliary in nature, but could also consider hemolysis with gallstones like in her spherocytosis or something like that.
Read 22 tweets
First, let's start w/ an initial PR:

A 49 y/o F w/ a PMH of HTN, ETOH/THC abuse p/w bilateral leg weakness that started a week ago following during an admission for CAP that has since gotten worse along with urinary and fecal incontinence
is it true weakness or asthenia?

If weakness is present, is it ascending/descending, any back pain, incontinence, sensory deficits?

is the weakness proximal, distal, both?

Also think vascular and myopathy causes
Read 25 tweets
Time for some #SpacedRepetition: @CPSolvers @DxRxEdu @rabihmgeha
Chat recap of the #ClinicalPearls #VirtualMorningReport

August 17th Episode 119:…
W / @MohitHarshMD @KromerHaylie & Ninand Bhat Image
Let's start with an initial problem representation:

A 75 y/o M w/ a PMH of COPD, CAD, & aortic valve replacement p/w 2 weeks of dyspnea on exertion, 1 month of LE edema, 20 lb weight loss & recent onset PND and Orthopnea
invoke the dyspnea pyramid (cardiac, pulmonary, anemia, metabolic) but addition of progressive edema and weight gain concerning for cardiac pathology

whenever we see dyspnea on exertion and bilateral LE edema we jump straight to CHF
Read 24 tweets
Time for some #SpacedRepetition: @CPSolvers @DxRxEdu @rabihmgeha
Chat recap of the #ClinicalPearls #VirtualMorningReport

August 12th Episode 115:…
w / Sonia Silinsky Krupnikova @Flower_freeland @pri_athavale
Teaching points @sukritibanthiya Image
Let’s start with an initial problem representation:

A 50 y/o F w/ a PMH of remote gastric bypass, anemia, MGUS & hereditary elliptocytosis p/w worsening fatigue, dyspnea on exertion, chronic chest discomfort and trouble sleeping at night
Looks like CHF

Also wondering if difficulty sleeping at night is orthopnea.

As well as if the difficulty doing tasks is due to SOB, extreme fatigue., or muscle weakness

Let's activate the dyspnea schema and connect some dots Image
Read 25 tweets
Time for some #SpacedRepetition: @CPSolvers @DxRxEdu @rabihmgeha
Chat recap of the #ClinicalPearls #VirtualMorningReport

August 11th Episode 114:…
W / @Anu08877649 Joshua Morris & @Rafameed
Teaching points illustration by @sukritibanthiya Image
Let’s start with an initial problem representation:

A 55 y/o M w/ no known PMH except a 30 pack-year history of tobacco abuse presents with recurrent syncope (lightheaded prodrome) over last 2 mon along w/ R shoulder pain, 15 lb weight loss for 3 months, and an occasional cough
An initial evaluation of syncope should involve ruling out mimickers like Sz or TIA

The fact that he was lying down during the episode is concerning for cardiogenic cause like an arrhythmia

Also, an autonomic given the lightheadedness while lying in bed… Image
Read 19 tweets
Time for some #SpacedRepetition: @CPSolvers @DxRxEdu @rabihmgeha
Chat recap of the #ClinicalPearls #VirtualMorningReport

August 10th Episode 113:…
w/ @kiaracamacho96 @RizwanDania & Maria Jose Vides
Teaching points illustration by Sukriti Banthiya Image
Let's start with an initial problem representation:

A 73 y/o M w/ a pmh of DM2, depression, hypoTh, BPH presents w/ a few days of nocturia & LE pain & brought in bc he was found lying on the floor of his bathroom disoriented after experiencing dizziness, blurry vision & falling
Was this fall a syncope or seizure?

Sounds like reflex vs orthostatic syncope but keeping all buckets open.

Foresee an EEG & MRI to check for seizures...

A hx of any cardiac disease will be helpful. also thinking about syncope mimics - stroke, seizure, hypoglycemia Image
Read 25 tweets
Let’s start with a problem representation:

A 42 y/o M w/ no PMH presents with confusion and syncope but prior to this he noted 4 months of worsening cervical LAD and oral ulcerations along with a 5kg weightloss, cough, SOB w/ exertion & voice changes
cervical adenopathy & oral ulcerations, hm

are these painful? mobile?

oral ulceration, makes us think fungal, sarcoid, &autoimmune as well

This could be TB (scrofula) or “king’s evil”, royal touch was believed to cure the disease until the 18th cent…
Read 25 tweets
Let’s start with an initial problem representation:

A 30 y/o M w/ a PMH of lupus, pericarditis, HTN presents with 2 mon of dyspnea on exertion, worse w/ exertion, episodic CP while denying fevers, drenching night sweats, cough or weight loss
Given her history of lupus, Autoimmune is again, as always, on the differential

He seems too young for CHF, but heart and lungs should be the initial focal point followed by anemia which is also unusual for a male at 30
Read 24 tweets
Let’s start with a problem representation:

A 30 y/o F presents w/ a 6-mon history of a nonproductive cough worse w/ activity, a recent-onset fever, blurred vision, dry eyes who was found to have uveitis, erythema nodosum, & crackles on PE along w/ hilar LAD & hypercalcemia
Let's start with the cough.

A chronic cough in a 30 y/o? hmmm

Cough thinking about a pulmonary process (anywhere from nose to alveoli) but also thinking about GI and cardiac etiologies causing cough as well
Read 26 tweets
Time for some #SpacedRepetition: @CPSolvers @DxRxEdu @rabihmgeha
Chat recap of the #ClinicalPearls #VirtualMorningReport

July 27th Day 102:…

w/ case presenter @sonyardavey and discussants Leticia Maciel & Andrew Sanchez Image
Let’s start with a problem representation:

An 84-y/o M with a PMH of CAD with CABG, HTN, hypothyroidism, adeno carcinoma of the duodenum s/p Whipple and chemo currently in remission, & Carpal Tunnel Syndrome (CTS) p/w 10 days of scrotal/leg swelling and fatigue w/o CP or SOB
The scrotal swelling always brings them in!!

With fluid overload: thinking about a problem of heart, liver, or kidneys. Remember to look up!

is the IVC blocked with congestion of internal pelvic veins and leg veins (uncommon)? medication side effect?

CAD/CABG 🔼 risk of CHF Image
Read 28 tweets
Let’s start with an initial problem representation:

A 31 yo M p/w 6 months of hematochezia, morning stiffness, diffuse symmetrical joint pains, & intermittent finger duskiness
intermittent duskiness? is this Raynaud's?

The overlap between GI and arthritis triggers spondyloarthopathies

BRBPR= lower GI bleed. Think colon masses/polyps, sigmoid diverticulosis (uncommon at this age but possible), anorectal disease (masses, hemorrhoids)
Read 25 tweets
Before we start, if you didn't check out @_HarryPaul_ twitter thread from last wk, 👉👉

Now the initial PR:

A 60 y/o M w/ PMH of relapsing MS dx (last flare 4 yrs ago) p/w unsteadiness, trouble focusing & weightloss was tx for MS flare w/o improvement
"difficulty focusing on objects" --> interesting

maybe he has diplopia, Check out this flow chart for this "blurry" topic

Is this JC virus reactivation with PML?natalizumab and some of the new oral agents can cause:… Image
Read 25 tweets
It's time for a slightly tardy #SpacedRepetition: @CPSolvers

Chat recap of the #ClinicalPearls #VirtualMorningReport

July 10th Day 91:…
w/ @AnnKumfer @DxRxEdu @rabihmgeha
Teaching points: @sukritibanthiya

Get ready for the @fernandbteich show Image
But first, we want to acknowledge @_HarryPaul_ who gave us all something to reflect on. #MichaelHickson…

Thanks for stepping up and sharing Harry!
Let’s start with a problem representation:

A 69-y/o F w/ a PMH of sinus cancer presents from an outside hospital with night sweats that started 4 wks ago along w/ rigors, fevers, nausea, early satiety, & weightloss found to have splenomegaly, lymphopenia, & elevated ESR/CRP
Read 27 tweets
On day 14 of neutropenia, an astute ID fellow noted this finding (photo) while examining a patient with fever. Underlying AML and ongoing chemotherapy.

What do you suspect? What work up do you suggest? Details and #MayoIDQ MCQ to follow...
65M acute myeloid leukemia. Rx: CLAG-M. Prophy ACV, posaconazole, Levo, inhaled pentamidine

D14 neutropenia: fever / chills
Exam: onychomycosis, rapidly evolving lesions in arms and torso (photo)

You asked for skin biopsy. Blood culture will grow what fungus?
Case diagnosis: disseminated fusariosis

Majority got the diagnosis correctly!
Blood culture: Fusarium sp.

Rx: AmBisome / voriconazole
Hope for neutrophil recovery!!!
Read 12 tweets
Let’s start with a problem representation:

An 80 yo F presents with worsening fatigue x 1 month, 1 week of DOE, and “dizziness” was found to be anemic, hypercalcemic with an AKI, elevated Gamma Gap with a IgM monoclonal Spike, & increased serum viscosity
Our main focus initially is her Chief Concern:
Lightheadedness and fatigue with SOB on exertion:
Causes include: cardiac/pulmonary/anemia/metabolic
Trigger DOE schema Image
Read 29 tweets
Let’s start with a problem representation:
A 30 yo M from Guatemala w/ a PMH of ETOH abuse who works in a warehouse presents w/ 1month of worsening SOB, non-productive cough, nausea, diarrhea, & 15 lb weight loss was found to be tachy, hypoxic, & tachypneic w/ 🔽 BS bilaterally
thinking about dyspnea pyramid right off the bat - pulmonary (airway, vasculature, parenchyma, etc.), cardiac, “bad” blood (anemia, carboxyhemoglobinemia) and acid-base disorders


Tachycardia always gets our attention as does the pulse ox
Read 33 tweets
Time for some #SpacedRepetition: @CPSolvers

Chat recap of the #ClinicalPearls #VirtualMorningReport

June 26th Day 83:…

w/ Neha Teekappanavar @DxRxEdu @rabihmgeha

Case Overview by @LindseyShipley8 Image
Let's start with an initial problem representation:

A 52 y/o F presents with 2 months of fatigue, 3 wks of mid back pain, foamy urine, hypersalivation, and swelling in her ankle and face

would look for systemic symptoms like weight loss, night sweats

Back pain age over 50 is a red flag to image

frothy urine...nephrotic?

foamy urine can indicate proteinuria although non-specific

clinical significance of foamy urine?…
Read 25 tweets
Let's start with a Problem Representation:

A 6o y/o F presents with 10 yrs of SOB, recent falls the last few months, increasing fatigue, constipation (1 BM every 8 days), and new-onset AMS found to have pancytopenia, 🔽Na, 🔽Glu, 🔽 Free T4, 🔽cortisol
From the get-go: Gait difficulties for 7 days, AMS, constipation

Enter MIST pneumonic for AMS

Hypercalcemia links constipation and AMS but Hyper CA doesn't explan dyspnea

she will have polyuria w/her hypercalcemia…
Read 25 tweets
Prior to case @medrants shared some pearls on the prior VMR case:

Patients with Lemierre syndrome have a high risk of new thromboembolic complications, clinical sequelae and death: an analysis of 712 cases…
Let's start with an initial problem representation:

A 49-yo M was found unresponsive laying in a park w/ an almost empty trazodone bottle that was filled layer, he was obtunded on exam w/o signs of trauma and found to have ⏫AG, ⏫Cr, ⏫ Osm Gap, ⏫QTc
Read 26 tweets

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